How young is too young to seek gender reassignment?

In a cottage decorated with butterflies to symbolize transformation, Katherine Boone recovered from the operation that had changed her, in the most intimate part of her body, from a biological male into a female.

Katherine Boone, who goes by Kat, right, talks with her surgeon, Dr. Christine McGinn, who is also a transgender woman, in New Hope, Pa., June 4, 2015. Boone underwent gender reassignment surgery to become female at just 18. The number of teenagers going through gender reassignment has been growing amid wider acceptance of transgender identity, more parental comfort with the treatment and the emergence of a number of willing practitioners. (Andrew Spear/The New York Times)

“I just want to hold Emma,” she said at the bed-and-breakfast in New Hope, Pennsylvania, run by the doctor who performed the operation in a hospital nearby. Emma is her black and white cat, at her home in central New York state, 250 miles away. Her childlike reaction was, perhaps, not surprising. Kat is just 18.

It is a transgender moment. President Barack Obama was hailed just for saying the word “transgender” in his State of the Union speech this year.

Bruce Jenner’s transition from male sex symbol to a female named Caitlyn has elevated her back to her public profile as a gold-medal decathlete at the 1976 Summer Olympics.

The question is no longer whether gender reassignment is an option, but rather, how young should it begin. While no law prohibits minors from receiving sex-change hormones or even surgery, insurers have generally refused to extend coverage for these procedures to those under 18.

Now advocates are fighting for coverage at an earlier age, beginning with hormone blockers at the onset of puberty. They say it is more seamless for a teenage boy to transition to becoming an adult woman, for example, if he does not first become a man.

“Some of these women are passing, but barely, when they transition at 40 or 50,” said Dr. Irene Sills, an endocrinologist who just retired from a practice treating transgender children, including Kat. “At 16 or 17, you are going to have such an easier life with this.”

Given that there are no proven biological markers for what is known as gender dysphoria, there is no medical consensus on the central question: whether teenagers — habitually trying on new identities and not known for foresight — should be granted an irreversible physical fix for what is still considered a psychological condition.

The debates invoke biology, ideology and emotion. Is gender dysphoria governed by a wiring of the brain or by genetic coding? How much does it stem from the pressure to fit into society’s boxes? Has the Internet liberated teenagers like Kat from a narrow view of how they should live, or seduced them by offering an answer they might later choose to reject?

“Basically you have clinics working by the seat of the pants, making these decisions, and depending on which clinic you go to, you get a different response,” said Dr. Jack Drescher, a New York City psychiatrist who helped develop the latest diagnostic criteria for gender dysphoria.

But, he asked, “Is it fair to make a child who’s never going to change wait till 16 or 18 to get treatment?”

A young science

As a freshman in high school, Kat Boone became depressed and withdrawn.

“I knew that the changes going on with puberty were not me,” Kat said. “I started to really hate my life, myself. I was uncomfortable with my body, my voice, and I just felt like I was really a girl.”

When she discovered the transgender world on the Internet, she had a flash of recognition. One night, she crept into her mother’s room and sat on the bed, crying. When she finally came out with what was bothering her, her mother’s first impulse was to comfort her, saying: “It’s OK. It’s OK.”

Kat’s father, Andrew, had moved out when she was in fifth grade, and it took a few months for Kat and her mother to find the courage to tell him. Gail Boone had a background in psychology, which helped her understand. Andrew Boone, an operations and project manager, had a harder time.

“I was really eating myself up because I couldn’t help this overwhelming feeling as if my child had died,” he said. “But here was my child right in front of me.”

It was the cutting that convinced them that if she could not live as a girl, Kat would kill herself. She still has two angry scars on her left forearm.

At 16 ½ , after seeing a therapist, Kat began taking estrogen and a blood-pressure drug, spironolactone, that is also used to block the actions of testosterone, to help her look more female.

The drive to treat children is relatively new. The puberty-blocking protocol gained legitimacy in 2009, when it was endorsed by the Endocrine Society, a physicians’ group. It calls for administering drugs normally used to treat precocious puberty, as well as prostate cancer and endometriosis.

The theory is that this drug-induced lull from 12 to 16 — sometimes younger — will help teenagers decide whether they truly are transgender, without committing to irreversible physical changes. But in practice, experts warn, once children have “socially transitioned” it is difficult to go back.

The blockers cost thousands of dollars a year, and like all drugs used for transgender treatment, have not been approved by the Food and Drug Administration for that use, though they may be prescribed “off label.” Some doctors have been able to drive the price down to $120 a month by getting the adult implant, which is much cheaper than the pediatric one, and stretching it out over two years instead of one.

While hormones for minors are sometimes covered by insurance, surgery almost never is. Kat’s surgeon, Dr. Christine McGinn, estimated that she had done more than 30 operations on children under 18, about half of them vaginoplasties for biological boys becoming girls, and the other half double mastectomies for girls becoming boys.

Kat’s parents trusted McGinn not only as a specialist, but also as a role model: She had been a dashing male doctor in the Navy, before becoming a beautiful female doctor in civilian life.

Advocates say extending treatment to teenagers will alleviate depression and suicide. The evidence is mixed. Complicating matters, studies suggest that most young children with gender dysphoria eventually lose any desire to change sex, and may grow up to be gay, rather than transgender. Once into adolescence, however, their dysphoria is more likely to stick.

Dr. Paul McHugh, a professor of psychiatry at Johns Hopkins, is skeptical of the use of surgery for a psychological condition, and even more so for children.

“Bruce Jenner — who cares?” said McHugh, who said he played a role in closing a transgender surgery program at Johns Hopkins about 35 years ago. “He’s a wonderfully successful person. He’s got all kinds of social networks. He’s got plenty of money. No one’s objecting to him if he wants to live as a woman. This is America, be my guest.

“But we’re talking about children with a future ahead of them.”

Under the knife

Kat went into the surgery with high hopes. Her goal was to start college as a woman.

They were able to book a date during spring break, when McGinn’s calendar begins filling up with college-bound patients.

It was too late to change some things, like Kat’s tenor voice and facial hair. She chose not to save sperm — to her, a revolting reminder of masculinity — so she cannot have children. It was the one sacrifice that gave her father a pang.

The operation involved deconstructing her male genitals and repurposing the nerves and skin as female anatomy. When it was over, Kat developed aspiration pneumonia and had vomiting and dry heaves for days.

These are normal reactions to anesthesia, narcotics and antibiotics, but McGinn said Kat was hit harder than most. Six weeks after the operation, she was still so weak she had to take the elevator at school instead of stairs.

At her two-month checkup, she had gained back half the weight she had lost, but still looked frail and self-conscious. She treated herself to a new hair color — strawberry blond — for graduation. She said she had “zero regrets.”

But she was anxious about having enough privacy in college, since her new vagina needs constant care or it will close off like a wound.

“The only thing I’m thinking about now is the room situation,” she said.

Last modified: July 7, 2015
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